December 2, 2012

APA rejects "hebephilia," last standing of three novel sexual disorders

To hear government experts on the witness stand in civil detention trials in recent months, the novel diagnosis of "hebephilia" was a fait accompli, just awaiting its formal acceptance into the upcoming fifth edition of the influential Diagnostic and Statistical Manual of Mental Disorders (DSM).

They were flat-out wrong.

In a stunning blow to psychology's burgeoning sex offender processing industry, the Board of Trustees of the American Psychiatric Association rejected the proposed diagnosis outright, not even relegating it to an appendix as meriting further study, its proponents' fall-back position.

The rejection follows the failure of two other sexual disorders proposed by the DSM-5's paraphilias subworkgroup. These were paraphilic coercive disorder (or a proclivity toward rape) and hypersexuality, an inherently hard-to-define construct that introduced the committee members' value judgments as to how much sex is within acceptable limits.

After abandoning those two disorders, the subworkgroup clung tenaciously to a whittled-down version of its proposed expansion of pedophilia to cover sexual attraction to early pubescent youngsters (generally in the age range of 11-14), ignoring widespread opposition from both within and outside of the APA.

The buzz is that senior psychiatrists in the APA were unhappy with the intransigence of psychologists in the subworkgroup who communicated the belief that if they just stuck to their guns, they could force the ill-considered proposal into the new manual, despite a lack of scientific support.

All three proposed sexual disorder expansions were widely critiqued by mental health professionals, especially those working in the forensic contexts in which they would be deployed. They led to a spate of critical peer-reviewed publications (including a historical overview of hebephilia by yours truly, published in Behavioral Sciences and the Law), and an open letter to APA leadership from more than 100 professionals, including prominent forensic psychologists and psychiatrists in the U.S. and internationally.

The unequivocal rejection sends a strong signal of the American Psychiatric Association's continuing reluctance to be drawn into the civil commitment quagmire, where pretextual diagnoses are being invoked as excuses to indefinitely confine sex offenders who have no genuine mental disorders. In marked contrast with the field of psychology, psychiatry leaders have expressed consistent concerns about the use of psychiatric labels to justify civil detention schemes.

Next time around, the APA might want to do a better job selecting committee members in the first place. The "paraphilias subworkgroup" was heavily biased in favor of hebephilia because of its domination by psychologists from the Canadian sex clinic that proposed the new disorder in the first place, and is the only entity doing research on it. But what a waste of time and energy to create a committee that comes up with wild and wacky proposals that are only going to end up getting shot down when the rubber meets the road.

Backpedaling on paradigm shift

As regular readers of this blog know, the DSM-5 developers' grand ambitions to bring forth a revolutionary "paradigm shift" produced alarm among mental health professionals and consumer advocacy groups both in the United States and internationally. The British Psychological Society, the UK's 50,000-member professional body, issued a strongly worded critique, and a coalition of psychological associations garnered more than 14,000 signatures on a petition opposing the wholesale lowering of diagnostic thresholds for disorder.

Yesterday's news release marked an about-face, with the APA now stressing that diagnostic changes in the DSM-5 were intended to be "very conservative."

"Our work has been aimed at more accurately defining mental disorders that have a real impact on people’s lives, not expanding the scope of psychiatry," said David J. Kupfer, MD, chair of the DSM-5 Task Force.

Consistent with this, several of the proposed changes that generated the most widespread alarm were rejected. The Board of Trustees rejected the highly controversial "attenuated psychosis syndrome" that could have created an epidemic of false positives, stigmatizing eccentric young people and lowering the threshold for prescribing potentially harmful antipsychotic drugs. It also backed away from an equally controversial, and complex, revamping of the personality disorders. These conditions, as well as a contentious Internet gaming disorder, will all be placed in "section 3" of the new manual as conditions meriting further study.

Allen Frances, the DSM-IV Task Force chair and a high-profile critic of the DSM-5 project, called the spin that the DSM-5 will have minimal impact on psychiatric diagnosis and treatment "misleading":

"This is an untenable claim that DSM 5 cannot possibly support because, for completely unfathomable reasons, it never took the simple and inexpensive step of actually studying the impact of DSM on rates in real world settings…. Except for autism, all the DSM 5 changes loosen diagnosis and threaten to turn our current diagnostic inflation into diagnostic hyperinflation. Painful experience with previous DSM's teaches that if anything in the diagnostic system can be misused and turned into a fad, it will be. Many millions of people with normal grief, gluttony, distractibility, worries, reactions to stress, the temper tantrums of childhood, the forgetting of old age, and 'behavioral addictions' will soon be mislabeled as psychiatrically sick and given inappropriate treatment."

Among the controversial diagnostic changes that will go forward in the DSM-5, due to be published in mid-2013:

Asperger’s syndrome is being eliminated as a separate disorder (it will be folded into an autism spectrum disorder)

Depression is being expanded to include some grief reactions

A brand-new "disruptive mood dysregulation disorder" has critics fearing psychiatric labeling of children who have temper tantrums

Two other sets of changes have particular relevance to forensic practitioners. Substance abuse disorders have been reframed as "behavioral addictions," which Frances warns could be a "slippery slope" leading to "careless overdiagnosis of internet and sex addiction and the development of lucrative treatment programs to exploit these new markets."

Posttraumatic stress disorder (PTSD) will be included in a new chapter on trauma and stress-related disorders, with four distinct diagnostic clusters instead of the current three, and "more attention to the behavioral symptoms that accompany PTSD." Some worry that the reconfigured PTSD may lend itself to misuse of the hot-button diagnosis in forensic cases.

12 comments
:

This is indded great news! Thank you for all your hard work Karen to help make this happen, and the same Kudos is extended to Dr. Wollert and all others who helped reign in this dangerous direction some members of the the APA wanted to go in. Congratulations on a hard fought battle! Some news out of Minnesota:

Yes, I am glad to read this as well. However, I have a feeling that the debate is not over yet.

I do wonder, though . . .

1) Does this official rejection also dispel the NOS inclusion related to "hebephilia"? Now that it is clear that such a proclivity is NOT a mental disorder and that psychiatry will not cater to forensics, the NOS entry would logically lose strength and dissipate as well, no?

2) The criteria for pedophilic disorder (new name) will not change. Since the upper age range set in the current list of criteria is 12/13, would that make a difference? As Allen Frances has said, the onset of puberty occurs at younger ages all the time and the current target range for pedophilia would actually be "10 and younger." With the upper age limit remaining at 12/13, confusion and debate are still likely to carry on (especially since age is irrelevant in the case of pedophilia). Shouldn't that 12/13 in the criteria for pedophilia be lowered to ensure consistency, clarity in the concept and to rectify this ongoing debacle completely once and for all?

Again, great news. You were a major force behind this, and I congratulate you.

"Logically," as you say, one might think that evaluators would no longer rely on "paraphilia not otherwise specified (NOS) hebephilia" as a diagnostic category meriting civil commitment. However, I predict that logic will not rule the day. Evaluators who are convinced that a former sex offender remains dangerous will continue to come up with whatever bogus diagnoses are necessary in order to justify civil commitment, which requires a mental disorder. I also predict greater usage of addiction language (as in alcohol addiction, sex addiction, etc.) and personality disorder (especially antisocial personality disorder) as grounds for commitment.

I have been wondering what the ramifications of these expansive definitions of so-called sexual deviance had been added would have been. My concern was it would have expanded the ways in which one could have been civilly committed.

Thank you for the work you and others put in to make this a reality. I was so happy to see this news, which marks a small but significant triumph of rationalism over hysteria and greed.

Following a link from your hebephilia resources page, I noticed Allen Frances and Michael First, in their article "Hebephilia Is Not a Mental Disorder in DSM-IV-TR and Should Not Become One in DSM-5" stated repeatedly that acting on "hebephilic" urges is a "serious crime." If we are in agreement that attraction to people 11-14 is not a mental disorder or even deviant (as First and Frances state) then why should it be a "serious crime" to act on these natural feelings with a consenting partner?

Hopefully the law code will one day reflect scientific truth and not social reactionism.

Thanks for your kind words about my contribution to the campaign against bogus psychiatric diagnosis. However, just because something is not a mental illness does not make it morally acceptable. Breaking into someone's house doesn't make one mentally ill. Nor is murder typically evidence of mental illness. In my experience, there is more than a smattering of self-serving delusional thinking when an adult claims that a sexual relationship with an 11-year-old was "consensual."

"In my experience, there is more than a smattering of self-serving delusional thinking when an adult claims that a sexual relationship with an 11-year-old was "consensual."

I agree with you wholeheartedly on this. However, I am curious: do you think that a sexual relationship involving a minor and adult might ever be a genuinely consensual one? I have read cases where adults who had engaged with adults when they were adolescents have recalled their respective relationships fondly. Some adolescents were actually the initiators. Of course, none of those instances involved an 11-year-old. That's young! I have yet to encounter a case where an 11-year-old would commit to sex with anyone, much less an adult.

In any case, regardless of consent, it is still illegal and for some substantially understandable reasons. The rejection of "hebephilia" by the APA review committee should, in no way, be viewed as a green light to act.

Oh, sorry; I almost forgot: many other countries with lower AoCs apparently concur that teens as young as 14 are legitimately able to consent. Are these laws based primarily on physical sexual development or some degree of psychological evaluation? I would be curious to find out how such a consensus is reached.

When it comes to psychosexual development, I think most would agree that there is a significant difference between an 11 year old and a 13-14 year old. In North America, most AoC laws are set at 16 or 18. Delusional thinking enters the equation when facts about the sexuality of teenagers are abandoned in favor of upholding social norms, which are culture-specific and without any legitimate scientific basis.

If there is any empirical evidence that an arbitrarily selected age is a reliable way to determine whether an individual is able to consent or whether or not a sexual relationship is based on consent, I would like to see it.

13 and 14 year olds have sexual thoughts and urges that sometimes involve adults. And as this battle over "hebephilia" has proven, sane adults have thoughts and urges that involve teenagers.

It should not be the role of practitioners in this field to make moralistic judgments about others' preferences when those preferences are not harmful. Pathologizing normal human sexuality will discredit not only the DSM, but the therapeutic professions in general -- just look at the damage that including homosexuality among the "paraphilia" group has inflicted, even years after it is no longer listed.

"When it comes to psychosexual development, I think most would agree that there is a significant difference between an 11 year old and a 13-14 year old."

Yes, but are 13-14-year-olds mentally capable of engaging in consensual sex with adults, especially older ones? Each youth develops at her or his own rate, so some might be, but the issue still begs for a question.

Apparently, the lower AoCs in many countries reflect the notion some cultures believe they do, but that doesn't mean that social complications won't arise.

Do you live in Europe, Liam?

"Delusional thinking enters the equation when facts about the sexuality of teenagers are abandoned in favor of upholding social norms, which are culture-specific and without any legitimate scientific basis."

I agree to a point regarding some facts being disregarded for the sake of meeting certain pretextual agendas, but there's more to social and sexual interaction than merely science. The psychological dynamics of any relationship are more complex than that.

"an arbitrarily selected age is a reliable way to determine whether an individual is able to consent"

What would you suggest? Not all youth develop the same, true, so some assumptions have to be made based on average. The courts DO take certain considerations into account. This is where input from both forensics and psychiatry come to bear.

"whether or not a sexual relationship is based on consent"

Sex without consent is rape. Sexual activity between an adult an adolescent isn't mentally aberrant, but where there is no consent, it is and should always be wrong and therefore unacceptable, regardless of age.

As for consent, see my previous response above.

"It should not be the role of practitioners in this field to make moralistic judgments about others' preferences"

Yes, and Karen has opposed this many times, as have I. This is also one reason why the APA rejected the proposal. I assume you are merely chiming in here with your agreement on this?

"when those preferences are not harmful."

Be careful with the use of blanket statements. Sex between adults and adolescents CAN be harmful, depending on the circumstances (as can many adult-adult relationships). I am not saying this is ALWAYS the case, but to say that such behavior is NEVER harmful is a dangerous generality to make (although I will say that every sexual relationship involving a PREPUBESCENT and an adult is necessarily and always harmful, but that's a different scenario than this). Each case must be examined separately. This is the reason why instances of adult-teen sex are questionable. Many relationships of this nature are not technically abusive, but close examination from a professional will determine whether or not that is the case.

Do you have any evidence to suggest that adult-teen sex is NEVER harmful? I would like to see it.

"just look at the damage that including homosexuality among the "paraphilia" group has inflicted, even years after it is no longer listed."

Who said that including homosexuality among the paraphilias caused damage? Its removal was due to social pressure, NOT any advance in science. From a socio-functional perspective, homosexuality provides no possibility of natural productivity. That said, I do have gay friends and respect them as human beings just the same.

Subscribe to newsletter

Karen Franklin, Ph.D. is a forensic psychologist and adjunct professor at Alliant University in Northern California. She is a former criminal investigator and legal affairs reporter. See her website for more professional background. If you find this blog's content helpful, you may subscribe to its digest version (via "subscribe" box, above) to automatically receive new posts.

Book reviews at Amazon:
Dr. Franklin is a frequent reviewer of books and movies. Browse her reviews here. If you find a review helpful, please give positive feedback. (Click on "Permalink" and then on "Yes," this review was helpful.)